Basic Information
Provider Information | |||||||||
NPI: | 1043225493 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALAMOGORDO PHYSICAL THERAPY & WELLNESS CENTER, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ALAMOGORDO PHYSICAL THERAPY | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2860 | ||||||||
Address2: |   | ||||||||
City: | ALAMOGORDO | ||||||||
State: | NM | ||||||||
PostalCode: | 883112860 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5754391397 | ||||||||
FaxNumber: | 5754372622 | ||||||||
Practice Location | |||||||||
Address1: | 2351 INDIAN WELLS | ||||||||
Address2: |   | ||||||||
City: | ALAMOGORDO | ||||||||
State: | NM | ||||||||
PostalCode: | 883105012 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5754391397 | ||||||||
FaxNumber: | 5754372622 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2006 | ||||||||
LastUpdateDate: | 10/02/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PATTILLO | ||||||||
AuthorizedOfficialFirstName: | MELYNN | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
AuthorizedOfficialTelephone: | 5754391397 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 3137 | NM | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 225100000X | 3137 | NM | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 83161 | 01 | NM | PRESBYTERIAN | OTHER | NMB2218 | 01 |   | MEDICARE B | OTHER | 27851729 | 05 | NM |   | MEDICAID | 2298 | 01 | NM | LOVELACE | OTHER |